Clinical Commissioning Group unreasonably refused to fund IVF

What happened

Mr A was involved in a road traffic accident and suffered an injury to his spinal cord. This left him paraplegic (when either both legs or the pelvis and some of the lower body are paralysed). His recovery was complicated by severe muscle spasms in his lower limbs, which required the insertion of a pump to deliver medication to the spinal cord to help him control this. Since doctors inserted this, Mr A has been unable to ejaculate and his GP and spinal surgeon suggested he seek fertility treatment.

Mr A and Ms B applied for NHS funding for IVF on three occasions and each time the CCG declined this.

What we found

There was no detailed evidence to support the CCG's assertion that it had appropriately considered Mr A's exceptional condition. It also provided no supporting information to demonstrate why Mr A's specific circumstances did not satisfy the exceptionality criteria.

Under the Individual Funding Request Operational Policy the CCG has to decide whether an individual has presented evidence of exceptional circumstances as described above. The evidence Mr A provided was clearly recorded in the CCG's documents. However, it was unclear precisely what evidence the CCG had used to base its decision, as this was not included in the records or decision letters.

The CCG had not clearly explained in its decision letters why it had not considered the circumstances to be exceptional in this case. For this reason we found that its decision not to fund the IVF was unreasonable.

There was no clear evidence to support the CCG's decision that the couple had not satisfied the exceptional circumstances criteria as set out in its Individual Funding Request Operational Policy.

Putting it right

The CCG reconsidered the request for funding under the exceptional circumstances criteria, and provided evidence to support its eventual decision. However, the CCG further declined funding.